Fetal acid-base and neonatal status after general and neuraxial anesthesia for elective cesarean section

Neonatal Outcome following External Cephalic Version (ECV)-Comparison between Vaginal Birth after Successful ECV and Elective Caesarean Section after Unsuccessful ECV

Introduction: In 3-6% of pregnancies, foetuses can be expected to be in a breech presentation near term. Consultation concerning further management of the pregnancy, including the option of an external cephalic version (ECV), is recommended by international guidelines (RCOG, ACOG, and DGGG). With regards to an ECV, there need to be two assumptions. Firstly, the procedure is safe, which has been shown adequately. Secondly, a vaginal birth after a successful ECV needs to prove to be non-inferior to the alternative of an elective caesarean section. The aim of this study is to assess the non-inferiority assumption. Methods: Overall, 142 singleton pregnancies were analysed that presented a foetus in a non-cephalic presentation and underwent an ECV near term between 2011 and 2020. The ECV was performed at 36 weeks of gestation for primiparous women and at 37/38 weeks of gestation for multiparous women. To assess neonatal outcome, the following parameters were recorded: arterial and venous umbilical cord blood pH, APGAR scores and admission to the neonatal intensive care unit (NICU). Data were analysed under the assumption that neonatal outcome does not differ between elective caesarean sections with or without an ECV in advance. Results: The success rate of an ECV was 56.3% (80/142). In the case of a successful ECV, there was a 77.5% (62/80) chance for a vaginal delivery. The mean arterial pH for neonates born vaginally after successful ECV was 7.262 (SD 0.089), compared to 7.316 (SD 0.051) for those born via elective caesarean section (p < 0.001). APGAR scores at 1, 5, and 10 min were similar between the groups, with a slightly higher proportion of neonates scoring below the median in the caesarean section group. Specifically, 13.7% (7/51) at 1 min, 15.7% (8/51) at 5 min, and 9.8% (5/51) at 10 min in the caesarean section group were below the median, compared to 4.92% (3/61), 4.92% (3/61), and 3.28% (2/61) in the vaginal birth group. NICU admission rates were 3.28% for vaginal births and 3.92% for elective caesarean sections (p > 0.05). Conclusions: Women with a successful ECV can expect a neonatal birth outcome after a vaginal birth that is non-inferior to an alternative elective caesarean section.

Do Delivery Mode and Anesthesia Management Alter Redox Setting in Neonates?

Objective Fetal-to-neonatal transition is accompanied by oxidative stress. The degree of oxidative damage may depend on several factors, such as delivery type and obstetric anesthesia type. The objective of the study was to determine if the delivery type and obstetric anesthesia type have an impact on oxidative stress levels in newborns.

Material and methods A prospective study included 150 newborns divided into three groups: neonates delivered vaginally, via cesarean section in general anesthesia, and via cesarean section in spinal anesthesia. Levels of pH, PaO2, lactate, glutathione peroxidase, and thiobarbituric acid reactive substance were quantified and compared between groups.

Results Vaginal delivery was followed by the highest lactate and thiobarbituric acid reactive substance levels and lowest pH, PaO2, and glutathione peroxidase levels. Higher values of thiobarbituric acid reactive substance, PaO2, and glutathione peroxidase and lower pH values were noted in neonates delivered in general anesthesia in comparison to neonates delivered in spinal anesthesia.

Conclusions Neonates delivered in general anesthesia were most prone to oxidative stress, while neonates delivered in spinal anesthesia were least affected by reactive oxygen species.

Comparison of the effect of general and spinal anesthesia for elective cesarean section on maternal and fetal outcomes: a retrospective cohort study

Background

Anesthesia is needed to ensure both maternal and fetal safety during cesarean sections. This retrospective cohort study compared maternal and fetal outcomes between general and spinal anesthesia for cesarean section based on perioperative hemodynamic parameters (pre- and postoperative systolic blood pressure, heart rate), mean difference of hematocrit and estimated blood loss, and neonatal Apgar scores at 1 and 5 min.

Methods

Data from electronic medical records of 331 singleton pregnancies between January 2016 and December 2018 were analyzed retrospectively; 44 cases were excluded, and 287 cases were assigned to the general group (n = 141) or spinal group (n = 146).

Results

Postoperative hemodynamic parameters were significantly higher in the general group than the spinal group (systolic blood pressure: 136.8 ± 16.7 vs. 119.3 ± 12.7 mmHg, heart rate: 93.2 ± 16.8 vs. 71.0 ± 12.7 beats/min, respectively, P < 0.001). The mean difference between the pre- and postoperative hematocrit was also significantly greater in the general than spinal group (4.8 ± 3.4% vs. 2.3 ± 3.9%, respectively, P < 0.001). The estimated blood loss was significantly lower in the spinal than general group (819.9 ± 81.9 vs. 856.7 ± 117.9 ml, P < 0.001). There was a significantly larger proportion of newborns with 5-min Apgar scores < 7 in the general than spinal group (6/141 [4.3%] vs. 0/146 [0%], respectively, P = 0.012).

Conclusions

General group is associated with more maternal blood loss and a larger proportion of newborns with 5-min Apgar scores < 7 than spinal group during cesarean sections.

Influence of anaesthetic technique on maternal and foetal outcome in category 1 caesarean sections - A prospective single-centre observational study

Background and Aims:

In category 1 caesarean section (CS), there is limited evidence regarding superior anaesthetic technique. Hence, this study was designed to study the influence of anaesthetic technique on the maternal and foetal outcome.

Methods:

Patient characteristics, indication for CS, decision-to-delivery interval (DDI), uterine incision-to-delivery time (UIDT), cord blood pH, Apgar scores and neonatal and maternal outcome were noted. Composite endpoint (Apgar score <7, umbilical cord blood pH <7.2, neonatal intensive care unit admission or death) was created for adverse neonatal outcome. Logistic regression was done to assess the influence of confounding factors on the occurrence of adverse neonatal outcome.

Results:

Of 123 patients who underwent category 1 cesarean section, 114 patients were included for analysis. The DDI and UIDT were comparable. One and 5-min Apgar scores were significantly lower in the group general anaesthesia (GA) than in the group spinal anaesthesia (SA). The umbilical cord blood pH was comparable (7.21 ± 0.15 vs 7.25 ± 0.11 in groups GA and SA, respectively). Neonatal intensive care admission and maternal outcome were comparable in both the groups. Subgroup analysis of patients with foetal heart rate of less than 100 showed that group GA had significantly lower 1-min Apgar scores and umbilical cord blood pH and significantly more neonatal admission and mortality. Binominal logistic regression showed that group GA (odds ratio 2.9, 95% confidence intervals 1.27-6.41) and gestational age were independently associated with adverse neonatal outcome.

Conclusion:

GA for category 1 CS was associated with increased incidence of adverse neonatal outcome.

Spinal fentanyl vs. sufentanil for post-operative analgesia after C-section: a double-blinded randomised trial

BACKGROUND

Fentanyl and sufentanil are the most commonly administered intrathecal lipophilic opioids worldwide, although their relative efficacy when given by this route is not well characterised. The primary endpoint of this prospective, randomised, double-blind study was to compare effective analgesia duration of intrathecal administered fentanyl 25 μg and sufentanil 2.5 or 5 μg, Second endpoints were to compare post-operative morphine consumption and incidence of side effects between these opioids dosages.

METHODS

After IRB approval, 180 full-term parturients undergoing elective Caesarean section were randomly allocated into three groups, according to the opioid added to 10 mg intrathecal hyperbaric bupivacaine: fentanyl 25 μg, sufentanil 2.5 μg or sufentanil 5 μg. Total effective analgesia was defined as time from spinal injection (T0) to first IV morphine requirement (T1) administered with a patient controlled intravenous pump. Statistical data analysis included non-parametric tests and chi-squared. A P value < 0.05 was considered statistically significant. Data are presented as median [interquartile ranges 25-75].

RESULTS

Duration of analgesia was significantly longer with sufentanil 2.5 μg (214 min [189-251]) and 5 μg (236 min [190-372]) compared to fentanyl 25 μg (187 min [151-230]) (P < 0.01). Morphine consumption at T1 + 4 h was lower in the sufentanil groups (6 mg [3-9] and 6 mg [2-10]) than in the fentanyl group (9 mg [5-13]) (P < 0.01). Incidence of adverse effects was not different between groups.

CONCLUSION

In the conditions of our study, sufentanil 5 μg was the opioid of choice, associated with the best quality of anaesthesia without increased incidence of side effects.

Association between preoperative maternal anxiety and neonatal outcomes: a prospective observational study

STUDY OBJECTIVE

Preoperative anxiety can be associated with poor postoperative clinical outcomes. We aimed to assess whether preoperative maternal anxiety level of obstetric patients scheduled for elective cesarean surgery has an effect on clinical outcome of the newborn.

DESIGN

A prospective observational study.

SETTING

Operating room.

PATIENTS

Sixty pregnant women with American Society of Anesthesiologists physical status 1 and 2 scheduled for elective cesarean surgery were enrolled.

INTERVENTIONS

All patients received spinal anesthesia with hyperbaric bupivacaine 12.5mg.

MEASUREMENTS

We performed a State-Trait Anxiety Inventory questionnaire to evaluate preoperative maternal anxiety. We used the Apgar scoring system to assess the physical condition of the newborn. Hemodynamic measurements (heart rate, systolic and diastolic blood pressure) were recorded at baseline, skin incision, childbirth, and 10, 15, and 30minutes after skin incision. The use of ephedrine, nausea, and vomiting were recorded as well.

MAIN RESULTS

Average preoperative maternal state anxiety score was 41.1±4.6, and trait anxiety score was 50.9±5.7. Average Apgar scores of newborns were 7.6±0.8 and 9.2±0.6, at first minute and fifth minute, respectively. We found no significant relationship between the anxiety scores and Apgar scores at first and fifth minute. Forty-two patients required ephedrine, 5 patients had nausea, and 5 patients had vomiting.

CONCLUSIONS

We concluded that there was no relationship between preoperative maternal anxiety scores and Apgar scores at the first and fifth minute.

Supplemental oxygen for caesarean section during regional anaesthesia

BACKGROUND

Supplementary oxygen is routinely administered to low-risk pregnant women during an elective caesarean section under regional anaesthesia; however, maternal and foetal outcomes have not been well established. This is an update of a review first published in 2013.

OBJECTIVES

The primary objective was to determine whether supplementary oxygen given to low-risk term pregnant women undergoing elective caesarean section under regional anaesthesia can prevent maternal and neonatal desaturation. The secondary objective was to compare the mean values of maternal and neonatal blood gas levels between mothers who received supplementary oxygen and those who did not (control group).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, issue 11), MEDLINE (1948 to November 2014) and EMBASE (1980 to November 2014). The original search was first performed in February 2012. We reran the search in CENTRAL, MEDLINE, EMBASE in February 2016. One potential new study of interest was added to the list of 'Studies awaiting Classification' and will be incorporated into the formal review findings during the next review update.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) of low-risk pregnant women undergoing an elective caesarean section under regional anaesthesia and compared outcomes with, and without, oxygen supplementation.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data, assessed methodological quality and performed subgroup and sensitivity analyses.

MAIN RESULTS

We found one new included study in this updated version. In total, our updated review includes 11 trials (with 753 participants). The low quality of evidence showed no significant differences in average Apgar scores at one minute (N = six trials, 519 participants; 95% confidence (CI) -0.16 to 0.31, P = 0.53) and at five minutes (N = six trials, 519 participants; 95% CI -0.06 to 0.06, P = 0.98). None of the 11 trials reported maternal desaturation. The very low quality of evidence showed that in comparison to room air, women in labour receiving supplementary oxygen had higher maternal oxygen saturation (N = three trials, 209 participants), maternal PaO2 (oxygen pressure in the blood; N = six trials, 241 participants), UaPO2 (foetal umbilical arterial blood; N = eight trials, 504 participants; 95% CI 1.8 to 4.9, P < 0.0001) and UvPO2 (foetal umbilical venous blood; N = 10 trials, 683 participants). There was high heterogeneity among these outcomes. A subgroup analysis showed no significant difference in UaPO2 between the two intervention groups in low-risk studies, whereas the high-risk studies showed a benefit for the neonatal oxygen group.

AUTHORS' CONCLUSIONS

Overall, we found no convincing evidence that giving supplementary oxygen to healthy term pregnant women during elective caesarean section under regional anaesthesia is either beneficial or harmful for either the mother or the foetus' short-term clinical outcome as assessed by Apgar scores. Although, there were significant higher maternal and neonatal blood gas values and markers of free radicals when extra oxygen was given, the results should be interpreted with caution due to the low grade quality of the evidence.

Supplemental oxygen for caesarean section during regional anaesthesia

BACKGROUND

Supplementary oxygen is routinely administered to low-risk pregnant women during an elective caesarean section under regional anaesthesia; however, maternal and foetal outcomes have not been well established.

OBJECTIVES

The primary objective was to determine whether supplementary oxygen given to low-risk term pregnant women undergoing elective caesarean section under regional anaesthesia can prevent maternal and neonatal desaturation. The secondary objective was to compare the mean values of maternal and neonatal blood gas levels between mothers who received supplementary oxygen and those who did not (control group).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2, 2012), MEDLINE (1948 to February 2012) and EMBASE (1980 to February 2012). We did not apply language restrictions.

SELECTION CRITERIA

We included randomized controlled trials of low-risk pregnant women undergoing an elective caesarean section under regional anaesthesia and compared outcomes with, and without, oxygen supplementation.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data, assessed methodological quality and performed subgroup and sensitivity analyses.

MAIN RESULTS

We included 10 trials with a total of 683 participants. Supplementary oxygen administration varied widely in dose and duration between trials. No cases of maternal desaturation were reported, although none of the 10 trials focused on maternal desaturation. Significant differences were noted in maternal oxygen saturation (higher with oxygen, N = three trials; mean difference (MD) 1.6%, 95% confidence interval (CI) 0.8 to 2.3, P < 0.0001), maternal PaO2 (oxygen pressure in the blood; higher with oxygen, N = six trials; MD 141.8 mm Hg, 95% CI 109.3 to 174.3, P < 0.00001), neonatal UaPO2 (foetal umbilical arterial blood; higher with oxygen, N = eight trials; MD 3.3 mm Hg, 95% CI 1.8 to 4.9, P < 0.0001) and UvPO2 (foetal umbilical venous blood; higher with oxygen, N = 10 trials; MD 5.9 mm Hg, 95% CI 3.2 to 8.5, P < 0.0001). No significant differences were reported in neonatal UapH (N = eight trials; MD 0.00, 95% CI -0.01 to 0.00, P = 0.26) and in average Apgar scores at one minute (N = five trials; MD 0.07, 95% CI -0.20 to 0.34, P = 0.6) and at five minutes (N = five trials; MD 0.00, 95% CI -0.06 to 0.05, P = 0.91).Only two out of 10 trials had a low risk of bias in all categories. When we separated the studies into low risk and high risk for bias, we found substantial statistical heterogeneity. None of the low-risk studies showed a significant difference in neonatal UaPO2 between the two intervention groups, whereas the high-risk studies showed a benefit for the neonatal oxygen group.The level of oxygen free radicals (malondialdehyde (MDA) and 8-isoprostane) was higher in participants who received supplementary oxygen (N = two trials; MD 0.2 µmol/L, 95% CI 0.1 to 0.4, P = 0.0002; MD 64.3 pg/mL, 95% CI 51.7 to 76.8, P < 0.00001, respectively).

AUTHORS' CONCLUSIONS

Current evidence suggests that supplementary oxygen given to healthy term pregnant women during elective caesarean section under regional anaesthesia is associated with higher maternal and neonatal oxygen levels (maternal SpO2, PaO2, UaPO2 and UvPO2) and higher levels of oxygen free radicals. However, the intervention was neither beneficial nor harmful to the neonate's short-term clinical outcome as assessed by Apgar scores.

Mode of anaesthetic for category 1 caesarean sections and neonatal outcomes

BACKGROUND

Birth by emergency caesarean section (CS) is common and often considered urgent (category 1). In the UK, over half of all category 1 CS are performed under general anaesthesia (GA). In this setting, little is known about the effect of the mode of anaesthesia on the neonate.

METHODS

A retrospective cohort study was performed using routinely collected de-identified data from Mater Health Services, Brisbane, Australia. The data set included 533 term babies born by category 1 CS for presumed fetal compromise between 2008 and 2011. Bivariate and multivariate analyses were undertaken.

RESULTS

The outcomes of 81 babies born by GA CS were compared with 452 by CS under regional anaesthesia (RA). Compared with a category 1 CS under RA, the decision-to-delivery interval for a GA CS was almost eight minutes faster (24.7 vs 32.6 minutes; P < 0.001). When adjusted for confounders, babies born by category 1 GA CS were significantly more likely to have an Apgar score < 7 at five minutes (aOR 6.89; 95%CI 1.79-26.55; P = 0.005), to require Neopuff or bag/mask ventilation for > 60 seconds (aOR 2.34; 95%CI 1.13-4.84; P = 0.022) and to be admitted to a neonatal intensive care nursery (aOR 2.24; 95%CI 1.16-4.31; P = 0.016).

CONCLUSIONS

General anaesthesia was associated with short-term neonatal morbidity of term babies born by category 1 CS for presumed fetal compromise, despite enabling a more rapid delivery of the baby. These data should help inform the discussion between anaesthetist and obstetrician, in balancing the risks and benefits of the mode of anaesthesia.

Trauma in pregnancy

Although serious trauma during pregnancy is uncommon, it remains a major cause of maternal and fetal death and presents a variety of patient care challenges. The anatomic and physiologic changes of pregnancy can affect both the nature of an injury and the body's response to it. Here, the author describes the mechanisms of traumatic injury during pregnancy, discusses the normal changes of pregnancy and their implications in the care of pregnant trauma patients, and offers strategies for assessment and treatment.

[Very preterm birth: is maternal anesthesia a risk factor for neonatal intubation in the delivery room?]

OBJECTIVE

To assess the risk of tracheal intubation at birth in very premature neonates related to the type of maternal anesthesia in case of elective cesarean.

POPULATION AND METHODS

All 219 live-born very premature neonates (28-32 weeks of gestation), delivered after an elective cesarean in the 27 maternity wards of 2 French semi-rural neonatal networks. Eighty-three percent (182/219) were delivered in level III maternity wards in university hospitals.

RESULTS

Of the very preterm neonates, 33.3% (73/219) were intubated in the delivery room, either for respiratory distress syndrome or a low APGAR score. Very preterm neonates delivered after maternal general anesthesia were more often intubated than those delivered after spinal anesthesia (48.7% vs 25.2%; OR: 2.8; 95% CI: 1.8-5.1). The risk of intubation related to maternal general anesthesia remained statistically significant after an adjustment for gestational age, fetal growth retardation, respiratory distress syndrome, type of maternity ward, and a propensity score that took into account maternal sociodemographic characteristics and the causes of very preterm birth (aOR: 3.4; 95% CI: 1.4-8.2). The risk of intubation related to general anesthesia was lower after adjusting for the 5-min APGAR score (aOR: 2.8; 95% CI: 1.0-7.3).

CONCLUSION

Very preterm neonates delivered after cesarean with general anesthesia require tracheal intubation in the delivery room more often than those delivered with spinal anesthesia. This study cannot assess a causal link between anesthesia and the need for neonatal intubation. However, neonatologists have to be aware of the type of maternal anesthesia because it may interfere with the non-invasive ventilation support policy of the very preterm neonate.

Where the O2 goes to: preservation of human fetal oxygen delivery and consumption at high altitude

Fetal growth is decreased at high altitude (> 2700 m). We hypothesized that variation in fetal O(2) delivery might account for both the altitude effect and the relative preservation of fetal growth in multigenerational natives to high altitude. Participants were 168 women of European or Andean ancestry living at 3600 m or 400 m. Ancestry was genetically confirmed. Umbilical vein blood flow was measured using ultrasound and Doppler. Cord blood samples permitted calculation of fetal O(2) delivery and consumption. Andean fetuses had greater blood flow and oxygen delivery than Europeans and weighed more at birth, regardless of altitude (+208 g, P < 0.0001). Fetal blood flow was decreased at 3600 m (P < 0.0001); the decrement was similar in both ancestry groups. Altitude-associated decrease in birth weight was greater in Europeans (-417 g) than Andeans (-228 g, P < 0.005). Birth weight at 3600 m was > 200 g lower for Europeans at any given level of blood flow or O(2) delivery. Fetal haemoglobin concentration was increased, decreased, and the fetal / curve was left-shifted at 3600 m. Fetuses receiving less O(2) extracted more (r(2) = 0.35, P < 0.0001). These adaptations resulted in similar fetal O(2) delivery and consumption across all four groups. Increased umbilical venous O(2) delivery correlated with increased fetal O(2) consumption per kg weight (r(2) = 0.50, P < 0.0001). Blood flow (r(2) = 0.16, P < 0.001) and O(2) delivery (r(2) = 0.17, P < 0.001) correlated with birth weight at 3600 m, but not at 400 m (r(2) = 0.04, and 0.03, respectively). We concluded that the most pronounced difference at high altitude is reduced fetal blood flow, but fetal haematological adaptation and fetal capacity to increase O(2) extraction indicates that deficit in fetal oxygen delivery is unlikely to be causally associated with the altitude- and ancestry-related differences in fetal growth.